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Sookaromdee P, Wiwanitkit V. Comment on Sonographic Evaluation of the Pancreas in Type 1 Diabetes Mellitus: A Case-control Study. J Med Ultrasound 2023; 31:339. [PMID: 38264608 PMCID: PMC10802864 DOI: 10.4103/jmu.jmu_206_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/28/2021] [Accepted: 09/30/2023] [Indexed: 01/25/2024] Open
Affiliation(s)
| | - Viroj Wiwanitkit
- Department of Community Medicine, Dr. DY Patil Vidhyapeeth, Pune, Maharashtra, India
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Meloni A, Pistoia L, Ricchi P, Positano V, Longo F, Borsellino Z, Cecinati V, Messina G, Corigliano E, Rosso R, Righi R, Peritore G, Renne S, Vallone A, Cademartiri F. Pancreatic T2* Magnetic Resonance Imaging for Prediction of Cardiac Arrhythmias in Transfusion-Dependent Thalassemia. J Clin Med 2023; 12:6015. [PMID: 37762955 PMCID: PMC10531669 DOI: 10.3390/jcm12186015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
We assessed the value of pancreatic T2* magnetic resonance imaging (MRI) for predicting cardiac events from a large prospective database of transfusion-dependent thalassemia (TDT) patients. We considered 813 TDT patients (36.47 ± 10.71 years, 54.6% females) enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. MRI was used to measure hepatic, pancreatic, and cardiac iron overload (IO), to assess biventricular function and atrial dimensions, and to detect replacement myocardial fibrosis. The mean follow-up was 50.51 ± 19.75 months. Cardiac complications were recorded in 21 (2.6%) patients: one with heart failure (HF) and 20 with arrhythmias. The single patient who developed HF had, at the baseline MRI, a reduced pancreas T2*. Out of the 20 recorded arrhythmias, 17 were supraventricular. Pancreatic T2* values were a significant predictor of future arrhythmia-related events (hazard ratio = 0.89; p = 0.015). Pancreas T2* remained significantly associated with future arrhythmias after adjusting for any other univariate predictor (age and male sex, diabetes, history of previous arrhythmias, or left atrial area index). According to the receiver-operating characteristic curve analysis for arrhythmias, a pancreas T2* < 6.73 ms was the optimal cut-off value. In TDT, pancreatic iron levels had significant prognostic power for arrhythmias. Regular monitoring and the development of targeted interventions to manage pancreatic IO may help improve patient outcomes.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Semplice a Valenza Dipartimentale Ricerca Clinica, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Paolo Ricchi
- Unità Operativa Semplice Dipartimentale Malattie Rare del Globulo Rosso, Azienda Ospedaliera di Rilievo Nazionale “Antonio Cardarelli”, 80131 Napoli, Italy;
| | - Vincenzo Positano
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
- Unità Operativa Complessa Bioingegneria, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy
| | - Filomena Longo
- Unità Operativa Day Hospital della Talassemia e delle Emoglobinopatie, Azienda Ospedaliero-Universitaria “S. Anna”, 44124 Cona, Italy;
| | - Zelia Borsellino
- Unità Operativa Complessa Ematologia con Talassemia, ARNAS Civico “Benfratelli-Di Cristina”, 90134 Palermo, Italy;
| | - Valerio Cecinati
- Struttura Semplice di Microcitemia, Ospedale “Santissima Annunziata”, 74123 Taranto, Italy;
| | - Giuseppe Messina
- Centro Microcitemie, Grande Ospedale Metropolitano “Bianchi-Melacrino-Morelli”, 89100 Reggio Calabria, Italy;
| | - Elisabetta Corigliano
- Ematologia Microcitemia, Ospedale San Giovanni di Dio—ASP Crotone, 88900 Crotone, Italy;
| | - Rosamaria Rosso
- Unità Operativa Talassemie ed Emoglobinopatie, Azienda Ospedaliero-Universitaria Policlinico “Vittorio Emanuele”, 95100 Catania, Italy;
| | - Riccardo Righi
- Diagnostica per Immagini e Radiologia Interventistica, Ospedale del Delta, 44023 Lagosanto, Italy;
| | - Giuseppe Peritore
- Unità Operativa Complessa di Radiologia, ARNAS Civico “Benfratelli-Di Cristina”, 90127 Palermo, Italy;
| | - Stefania Renne
- Struttura Complessa di Cardioradiologia-UTIC, Presidio Ospedaliero “Giovanni Paolo II”, 88046 Lamezia Terme, Italy;
| | - Antonino Vallone
- Reparto di Radiologia, Azienda Ospedaliera “Garibaldi” Presidio Ospedaliero Nesima, 95126 Catania, Italy;
| | - Filippo Cademartiri
- Department of Radiology, Fondazione Gabriele Monasterio CNR-Regione Toscana, 56124 Pisa, Italy; (A.M.); (L.P.); (V.P.)
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Ibrahim AS, Abd El-Fatah AH, Abd El-Halim AF, Mohamed FF. Serum Ferritin Levels and Other Associated Parameters with Diabetes Mellitus in Adult Patients Suffering from Beta Thalassemia Major. J Blood Med 2023; 14:67-81. [PMID: 36785546 PMCID: PMC9921443 DOI: 10.2147/jbm.s390666] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/12/2023] [Indexed: 02/08/2023] Open
Abstract
Background Although beta thalassemia major (BTM) patients are properly treated with blood transfusions in accompany with iron chelation therapy, they suffer from complications, such as diabetes mellitus (DM). Purpose The purpose was to detect the critical serum ferritin level and other parameters correlated with DM among adult BTM patients. Also, it was to study whether each of these parameters is associated with a certain period of age. Patients and Methods This study included 200 adult BTM patients. A cross-sectional study was carried out. Patients clinical and laboratory variables, such as ferritin levels, and fasting blood glucose (FBS) were extracted from medical records at Zagazig University Hospital, Egypt. Liver and cardiac iron contents were assessed using MRI T2* methods. Statistical analysis was performed using IBM SPSS V26.0 software package. Results The overall frequency of DM over the total sample equals 6.5%. There were no impaired fasting glucose (IFG) in the medical records. Statistical significance between serum ferritin and DM was (P = 0.014). The serum ferritin 2500 ng/mL with age group (27-<32) years-old were risk factors. The distributions of DM according to BMI were (3.5%) of class overweight. Significant association between DM and BMI was (r = 0.357, P < 0.001). Liver MRI T2* has significant correlation with serum ferritin, but cardiac MRI T2* was poorly correlated. Association between liver and cardiac MRI T2* was not found. Conclusion Age group (27-<32) years-old and ferritin >2500 ng/mL should be properly treated immediately. The serum ferritin and BMI of class "overweight" were risk factors for DM. Factors such as diet should be followed. Serum ferritin can be used for estimating liver iron content for economic factors. But cardiac MRI T2* must be performed for evaluating cardiac iron accurately.
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Affiliation(s)
- Ahmed Saleh Ibrahim
- Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt,Correspondence: Ahmed Saleh Ibrahim, Tel +20 109 232 6689, Email
| | | | | | - Farid Fawzy Mohamed
- Department of Internal Medicine, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Zhang Z, Hou B, Du G, Sun P, Guan W, Lin Q, Han B, Yu W. Association of hepatic/pancreatic iron overload evaluated by quantitative T2* MRI with bone mineral density and trabecular bone score. BMC Endocr Disord 2023; 23:2. [PMID: 36597099 PMCID: PMC9809119 DOI: 10.1186/s12902-022-01262-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Iron-overloaded patients are recognized as presenting an increased risk of osteoporosis. However, studies on the correlation between osteoporosis and organ iron overload are controversial or scarce. The aim of this study is to assess bone mineral density (BMD) and trabecular bone score (TBS) in correlation with hepatic and pancreatic iron overload. METHODS Forty-one patients diagnosed with hemoglobinopathies, were studied. BMDs of the lumbar spine (LS), femoral neck (FN), and total hip (TH) were analyzed by Dual-energy X-ray absorptiometry (DXA) scan. LS bone quality was derived from each spine DXA examination using the TBS analysis. Hepatic and pancreatic iron overload were obtained with a multi-echo gradient echo T2* technique. RESULTS Abnormal microarchitecture and abnormal bone mass were observed in 19/41 (46.3%) and 9/41 (22.0%) patients, respectively. For 26 males, BMD, T-score and Z-score of LS were significantly lower among subjects with moderate-severe hepatic iron-overload than their counterparts, as it is between no- and pancreatic iron-overload groups. For 15 females, patients with moderate-severe hepatic iron-overload had significantly lower BMD and T-score of FN and TH, and patients with pancreatic iron-overload had significantly lower BMD, T-score of FN, and lower BMD, T-score and Z-score of TH than their counterparts. Moreover, pancreatic T2*-value was positively correlated with BMD and T-score at all analyzed sites and Z-score at TH. CONCLUSION These data showed lower bone mass in patients with organ iron overload, particularly for LS in males, FN and TH in females. TBS may well represent a complementary tool for the evaluation of bone quality and the risk of fracture in iron-overloaded patients.
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Affiliation(s)
- Zaizhu Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Bo Hou
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Guiying Du
- Department of Radiology, TEDA International Cardiovascular Hospital, Tianjin, China
| | - Pengtao Sun
- Department of Radiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wenmin Guan
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qiang Lin
- Department of Radiology, Beijing Arion cancer center, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
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Meloni A, Positano V, Pistoia L, Cademartiri F. Pancreatic iron quantification with MR imaging: a practical guide. Abdom Radiol (NY) 2022; 47:2397-2407. [PMID: 35596775 DOI: 10.1007/s00261-022-03552-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/30/2022]
Abstract
Accurate determination of pancreatic iron status is crucial for preventing impairment of the exocrine and endocrine function of the pancreas and for prospectively stratifying the cardiac iron risk. The following article should be a sort of practical guide for radiologists interested in quantifying pancreatic iron overload by Magnetic Resonance Imaging (MRI). After a brief background on iron-deposition diseases, we will describe basic principles and relative advantages and disadvantages of the more widely used and clinically feasible MRI-based techniques for pancreatic iron assessment. These methods can be classified into signal intensity ratio (SIR) and relaxometry methods. We will examine different technical aspects representing the key for accurate and precise relaxation time measurement.
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Affiliation(s)
- Antonella Meloni
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Vincenzo Positano
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Laura Pistoia
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Via Moruzzi, 1, 56124, Pisa, Italy.
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Link between Genotype and Multi-Organ Iron and Complications in Children with Transfusion-Dependent Thalassemia. J Pers Med 2022; 12:jpm12030400. [PMID: 35330400 PMCID: PMC8950605 DOI: 10.3390/jpm12030400] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 01/27/2023] Open
Abstract
We evaluated the impact of the genotype on hepatic, pancreatic and myocardial iron content, and on hepatic, cardiac and endocrine complications in children with transfusion-dependent β-thalassemia (β-TDT). We considered 68 β-TDT patients (11.98 ± 3.67 years, 51.5% females) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia network. Iron overload was quantified by T2* technique and biventricular function by cine images. Replacement myocardial fibrosis was evaluated by late gadolinium enhancement technique. Three groups of patients were identified: homozygous β+ (N = 19), compound heterozygous β0β+ (N = 24), and homozygous β0 (N = 25). The homozygous β0 group showed significantly lower global heart and pancreas T2* values than the homozygous β+ group. Compared to patients with homozygous β+ genotype, β0β+ as well as β0β0 patients were more likely to have pancreatic iron overload (odds ratio = 6.53 and 10.08, respectively). No difference was detected in biventricular function parameters and frequency of replacement fibrosis. No patient had cirrhosis/fibrosis, diabetes or heart failure, and the frequency of endocrinopathies was comparable among the groups. In pediatric β-TDT patients, there is an association between genotype and cardiac and pancreatic iron overload. The knowledge of patients’ genotype can be valuable in predicting some patients’ phenotypic features and in helping the clinical management of β-TDT patients.
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Wagner R, Eckstein SS, Yamazaki H, Gerst F, Machann J, Jaghutriz BA, Schürmann A, Solimena M, Singer S, Königsrainer A, Birkenfeld AL, Häring HU, Fritsche A, Ullrich S, Heni M. Metabolic implications of pancreatic fat accumulation. Nat Rev Endocrinol 2022; 18:43-54. [PMID: 34671102 DOI: 10.1038/s41574-021-00573-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/15/2022]
Abstract
Fat accumulation outside subcutaneous adipose tissue often has unfavourable effects on systemic metabolism. In addition to non-alcoholic fatty liver disease, which has received considerable attention, pancreatic fat has become an important area of research throughout the past 10 years. While a number of diagnostic approaches are available to quantify pancreatic fat, multi-echo Dixon MRI is currently the most developed method. Initial studies have shown associations between pancreatic fat and the metabolic syndrome, impaired glucose metabolism and type 2 diabetes mellitus. Pancreatic fat is linked to reduced insulin secretion, at least under specific circumstances such as prediabetes, low BMI and increased genetic risk of type 2 diabetes mellitus. This Review summarizes the possible causes and metabolic consequences of pancreatic fat accumulation. In addition, potential therapeutic approaches for addressing pancreatic fat accumulation are discussed.
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Affiliation(s)
- Robert Wagner
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Sabine S Eckstein
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Felicia Gerst
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Jürgen Machann
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Section of Experimental Radiology, Department of Diagnostic and Interventional Radiology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Benjamin Assad Jaghutriz
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Annette Schürmann
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Experimental Diabetology, German Institute of Human Nutrition (DIfE), Potsdam-Rehbrücke, Germany
- Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | - Michele Solimena
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Molecular Diabetology, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden (PLID), Helmholtz Center Munich, University Hospital and Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Stephan Singer
- Institute of Pathology, University of Tübingen, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General, Visceral, and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Andreas L Birkenfeld
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Hans-Ulrich Häring
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Andreas Fritsche
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Susanne Ullrich
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Tübingen, Germany
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Martin Heni
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.
- German Center for Diabetes Research (DZD), Tübingen, Germany.
- Department of Internal Medicine, Division of Diabetology, Endocrinology, and Nephrology, Eberhard Karls University Tübingen, Tübingen, Germany.
- Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, University Hospital Tübingen, Tübingen, Germany.
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Anterior Pituitary Volume in Patients with Transfusion Dependent Anemias: Volumetric Approaches and Relation to Pituitary MRI‑R2. Clin Neuroradiol 2021; 32:259-267. [PMID: 34709410 PMCID: PMC8894216 DOI: 10.1007/s00062-021-01111-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/04/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE Anterior pituitary iron overload and volume shrinkage is common in patients with transfusion-dependent anemia and associated with growth retardation and hypogonadotropic hypogonadism. We investigated the accuracy of different MRI-based pituitary volumetric approaches and the relationship between pituitary volume and MRI-R2, particularly with respect to growth and hypogonadism. METHODS In 43 patients with transfusion-dependent anemia (12-38 years) and 32 healthy controls (12-72 years), anterior pituitary volume was measured by a sagittal T1 GRE 3D sequence at 1.5T and analyzed by 3D semi-automated threshold volumetry (3D-volumetry). This reference method was compared with planimetric 2D-volumetry, approximate volume calculations, and pituitary height. Using a multiple SE sequence, pituitary iron as MRI-R2 was assessed by fitting proton signal intensities to echo times. Growth and hypogonadism were obtained from height percentile tables and patients' medical charts. From body surface area and age adjusted anterior pituitary volumes of controls, Z‑scores were calculated for all subjects. Separation of controls and patients with respect to Z and pituitary R2 was performed by bivariate linear discriminant analysis. RESULTS Tuned 2D volumes showed highest agreement with reference 3D-volumes (bias -4.8%; 95% CI:-8.8%|-0.7%). A linear discriminant equation of Z = -17.8 + 1.45 · R2 revealed optimum threshold sensitivity and specificity of 65% and 100% for discrimination of patients from controls, respectively. Of correctly classified patients 71% and 75% showed hypogonadism and growth retardation, respectively. CONCLUSION Accurate assessment of anterior pituitary size requires 3D or precise 2D volumetry, with shorter analysis time for the latter. Anterior pituitary volume Z‑scores and R2 allow for the identification of patients at risk of pituitary dysfunction.
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Atmakusuma TD, Hasibuan FD, Purnamasari D. The Correlation Between Iron Overload and Endocrine Function in Adult Transfusion-Dependent Beta-Thalassemia Patients with Growth Retardation. J Blood Med 2021; 12:749-753. [PMID: 34429676 PMCID: PMC8380285 DOI: 10.2147/jbm.s325096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022] Open
Abstract
Background Iron overload is a major problem in patients with transfusion-dependent beta-thalassemia (TDT). Reports on the correlation between iron overload and endocrine function with growth retardation in such a population in Indonesia have not been established. Therefore, this study aims to obtain a profile of iron load and endocrine function of adult transfusion dependent beta-thalassemia patients and their correlation with growth retardation. Methods A cross-sectional study was performed, involving adult homozygous and HbE beta-thalassemia patients receiving blood transfusions at the Cipto Mangunkusumo Hospital, Jakarta. Iron overload was represented by serum ferritin (FS) and transferrin saturation (TS), while the endocrine function was examined by the Thyroid Stimulating Hormone-sensitive (TSHs), free T4 (fT4), and insulin-like growth factor-1 (IGF-1). The results were analyzed using bivariate analysis plus Pearson and Spearman correlation tests. Results In general, 58 subjects were selected from 224 adult transfusion dependent beta- thalassemia patients, consisting of 31 males (53.4%) and 27 females (46.6%). Furthermore, their median age was 21 (18-24) years, while the subclinical hypothyroid proportion was 32.7% and low IGF-1 levels were detected in 79.3% of the total population. There was a weak negative correlation between FS and fT4 (Spearman rho=-0.361; p=0.003), as well as IGF-1 (Spearman rho=-0.313; p=0.008), but FS and TSHs had no correlation (Spearman rho=0.074; p=0.29). Also, there was no correlation between ST with TSHs (Spearman rho=0.003; p=0.492), fT4 (Spearman rho=0.018; p=0.448), and IGF-1 (Spearman rho=-0.142; p=0.143). Conclusion Based on serum ferritin, iron overload is discovered to have a negative correlation with free T4 and insulin-like growth factor-1.
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Affiliation(s)
- Tubagus Djumhana Atmakusuma
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Faizal Drissa Hasibuan
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Yarsi Hospital, Jakarta, Indonesia
| | - Dyah Purnamasari
- Endocrine and Metabolic Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo General Hospital/Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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10
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Value of liver iron concentration in healthy volunteers assessed by MRI. Sci Rep 2020; 10:17887. [PMID: 33087836 PMCID: PMC7577999 DOI: 10.1038/s41598-020-74968-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 09/24/2020] [Indexed: 01/09/2023] Open
Abstract
Iron overload is a relatively common clinical condition resulting from disorders such as hereditary hemochromatosis, thalassemia, sickle cell disease, and myelodysplasia that can lead to progressive fibrosis and eventually cirrhosis of the liver. Therefore, it is essential to recognize the disease process at the earliest stage. Liver biopsy is the reference test for the assessment of liver fibrosis. It also allows for quantifying liver iron concentration (LIC) in patients. However, this is an invasive method with significant limitations and possible risks. Magnetic resonance imaging (MRI) and evaluation of the R2* relaxation rate can be an alternative to biopsy for assessing LIC. However, it causes a need for accurate R2* data corresponding to standard value for further comparison with examined patients. This study aimed to assess the normative values of liver R2* in healthy individuals. A total of 100 volunteers that met established criteria were enrolled in the study: 36 (36%) men and 64 (64%) women. The mean age was 22.9 years (range 20 to 32 years). R2* was estimated by an MRI exam with a 1.5 T clinical magnetic resonance scanner. Images for measuring the LIC and liver fat concentration were obtained using the IDEAL-IQ technique for liver imaging. The Mean (SD) liver R2* was 28.34 (2.25) s−1 (95% CI, 27.78–28.90, range 23.67–33.00 s−1) in females, 29.57 (3.20) s−1 (95% CI, 28.49–30.66, range 23.93–37.77 s−1) in males, and 28.72 (2.69) s−1 (range 23.67–37.77 s−1) in the whole group. R2* value in this particular population with a high proportion of young women did not exceed 38 s−1. In the absence of fibrosis or steatosis, liver stiffness and fat fraction did not show any relationship with R2*.
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Wurschi GW, Mentzel HJ, Herrmann KH, Krumbein I, Beck JF, Reichenbach JR, Kentouche K. MRI as an alternative to serum ferritin for diagnosis of iron overload in children in the context of immune response after stem cell transplantation. Pediatr Transplant 2019; 23:e13583. [PMID: 31535426 DOI: 10.1111/petr.13583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/18/2019] [Accepted: 08/07/2019] [Indexed: 12/30/2022]
Abstract
Multiple blood cell transfusions may cause iron overload or even liver fibrosis, requiring early diagnosis and intervention. SF is the standard for estimating iron levels in the body, but it also increases with inflammation. We hypothesized that T2 * magnetic resonance (MR) relaxometry is a more accurate alternative for follow-up in pediatric patients before and after allogenic SCT. Twenty-three children (mean age 10.2 years, 10 female, 13 male) were evaluated prospectively before SCT as well as at least 1 year after SCT with T2 * relaxometry on a 1.5 T MR-scanner to estimate liver iron concentrations from the T2 * values ("MR-Fe"). The results were compared with SF, while also considering CRP, and correlated with the number of transfusions. Overall, 24.3 transfusions were administered in average, mainly within 100 days of SCT (mean 10.5 units). Both MR-Fe and SF increased after SCT and decreased in the absence of new transfusions 1 year later without chelate therapy. This suggests regeneration of LP and iron loss, although the original states were not reached. Additionally, simultaneous peaks of CRP and SF were observed directly after SCT. MR-Fe did neither reveal these peaks nor was it associated with CRP (P = .39). We postulate that these early CRP and SF peaks after SCT are probably related to inflammatory reactions and not to iron overload. Thus, SF is not reliable for iron overload diagnosis after SCT in every condition. Beside this interaction, SF and MR-Fe revealed similar accuracy. MRI, however, has practical and economical disadvantages in routine estimation of iron.
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Affiliation(s)
- Georg W Wurschi
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karl-Heinz Herrmann
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Ines Krumbein
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - James F Beck
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Juergen R Reichenbach
- Medical Physics Group, Institute of Diagnostic and Interventional Radiology, University Hospital Jena, Friedrich Schiller University, Jena, Germany
| | - Karim Kentouche
- Section of Pediatric Hematology and Oncology, Department of Pediatrics, University Hospital Jena, Friedrich Schiller University, Jena, Germany
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Glucose dysregulation in patients with iron overload: is there a relationship with quantitative pancreas and liver iron and fat content measured by MRI? Eur Radiol 2019; 30:1616-1623. [PMID: 31712958 DOI: 10.1007/s00330-019-06487-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/27/2019] [Accepted: 10/09/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim was to investigate the relationship between pancreatic and hepatic iron and fat to glucose metabolism in patients with iron overload and address conflicting results in literature as regards the relationship between pancreas iron and glucose dysregulation. METHODS We retrospectively evaluated pancreatic and hepatic R2*, fat fraction (FF), liver iron concentration (LIC), and glucose metabolism in 105 patients with iron overload obtained with a multi-echo gradient echo R2* technique and assessed the correlation between pancreatic R2* and FF to glucose dysregulation. RESULTS There were no significant differences in pancreatic R2*, liver R2*, and FF in patients with iron overload and glucose dysregulation compared to those with normoglycemia (p = 0.435, p = 0.674, and p = 0.976), whereas pancreatic FF was significantly higher, 23.5% vs 16.7% respectively (p = 0.011). Pancreatic FF and R2* demonstrated an area under the curve of 0.666 and 0.571 for discriminating glucose dysregulation. Pancreatic FF of 26.2% yielded specificity and sensitivity of 80% and 45% for prediction of glucose dysregulation. Pancreatic R2* weakly correlated with pancreatic FF, r = 0.388 (p < 0.001), and liver R2*, r = 0.201 (p = 0.033), and showed no correlation with hepatic FF r = -0.013 (p = 0.892) or LIC categories (p = 0.493). CONCLUSION Pancreatic FF but not pancreatic R2* was associated with glucose dysregulation in patients with iron overload. Prior studies reporting correlation of pancreatic R2* to glucose dysregulation likely relate from inadequate MRI technique or analysis employed, which unlike our study did not perform simultaneous measurements of fat and iron essential to avoid their confounding effects during quantitative analysis. KEY POINTS • Pancreatic fat fraction, unlike iron, is associated with glucose dysregulation in iron overload. • Simultaneous measurement of pancreatic iron and fat content with MRI is essential to avoid confounding effects of one another during quantitative analysis. • Pancreatic fat fraction could be utilized to predict glucose dysregulation in iron overload states.
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Multicenter validation of the magnetic resonance T2* technique for quantification of pancreatic iron. Eur Radiol 2018; 29:2246-2252. [PMID: 30338366 DOI: 10.1007/s00330-018-5783-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/28/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To assess the transferability of the magnetic resonance imaging (MRI) multislice multiecho T2* technique for pancreatic iron overload assessment. METHODS Multiecho T2* sequences were installed on ten 1.5-T MRI scanners of the three main vendors. Five healthy subjects (n = 50) were scanned at each site. Five patients with thalassemia (n = 45) were scanned locally at each site and were rescanned at the reference site within 1 month. T2* images were analyzed using a previously validated software and the global pancreatic T2* value was calculated as the mean of T2* values over the head, body, and tail. RESULTS T2* values of healthy subjects were above 26 ms and showed inter-site homogeneity. The T2* values measured in the MRI sites were comparable to the correspondent values observed in the reference site (12.02 ± 10.20 ms vs 11.98 ± 10.47 ms; p = 0.808), and the correlation coefficient was 0.978 (p < 0.0001). Coefficients of variation (CoVs) ranged from 4.22 to 9.77%, and the CoV for all the T2* values independently from the sites was 8.55%. The intraclass correlation coefficient (ICC) for each MRI site was always excellent and the global ICC was 0.995, independently from the sites. The mean absolute difference in patients with pancreatic iron (n = 39) was -0.15 ± 1.38 ms. CONCLUSION The gradient-echo T2* MRI technique is an accurate and reproducible means for the quantification of pancreatic iron and may be transferred among MRI scanners by different vendors in several centers. KEY POINTS • The gradient-echo T2* MRI technique is an accurate and reproducible means for the quantification of pancreatic iron. • The gradient-echo T2* MRI technique for the quantification of pancreatic iron may be transferred among MRI scanners by different vendors in several centers. • Pancreatic iron might serve as an early predictor of cardiac siderosis and is the strongest overall predictor of glucose dysregulation.
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Bozdağ M, Bayraktaroğlu S, Aydınok Y, Çallı MC. MRI assessment of pituitary iron accumulation by using pituitary-R2 in β-thalassemia patients. Acta Radiol 2018; 59:732-739. [PMID: 28882060 DOI: 10.1177/0284185117730099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Patients with thalassemia major (TM) require repeated blood transfusions, which leads to accumulation of iron in a wide variety of tissues. Accumulation of iron in the pituitary gland can lead to irreversible hypogonadotropic hypogonadism (HH) in this group of patients. Purpose To investigate the reliability of pituitary-R2 as a marker to estimate the extent of pituitary iron load by comparing the pituitary magnetic resonance imaging (MRI) findings with hepatic iron load and serum ferritin levels. Material and Methods A total of 38 β-TM patients were classified into HH (group A, n = 18) and non-HH (group B, n = 17) groups. A third group, group C, consisted of 17 healthy participants. Each participant underwent 1.5-T MRI examinations. Pituitary gland heights (PGH), pituitary-R2 values, and liver-R2 values were measured by using multi-echo spin-echo sequences. Results Pituitary-R2 values were significantly higher in group A compared with group B ( P < 0.05). A positive correlation was detected between the pituitary-R2 values and serum ferritin levels in TM patients ( P < 0.01). A threshold value of 14.1 Hz for pituitary-R2 was found to give a high specificity and sensitivity in distinguishing the TM patients with HH from those with normal pituitary functions. PGH measurements were significantly lower in group A compared with group B ( P < 0.05). Conclusion MRI-assessed pituitary-R2 seems to be a reliable marker for differentiating the TM patients with normal pituitary function from those with secondary hypogonadism due to iron toxicity.
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Affiliation(s)
- Mustafa Bozdağ
- Department of Radiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | | | - Yeşim Aydınok
- Department of Pediatrics, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mehmet Cem Çallı
- Department of Radiology, Ege University Faculty of Medicine, Izmir, Turkey
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Karimi M, Amirmoezi F, Haghpanah S, Ostad S, Lotfi M, Sefidbakht S, Rezaian S. Correlation of serum ferritin levels with hepatic MRI T2 and liver iron concentration in nontransfusion beta-thalassemia intermediate patients: A contemporary issue. Pediatr Hematol Oncol 2017; 34:292-297. [PMID: 29190176 DOI: 10.1080/08880018.2017.1400135] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Beta-thalassemia intermediate is a genetic disease that is milder than beta-thalassemia major. The T2* magnetic resonance imaging (MRI) technique is currently the gold standard for iron load detection. However, it is expensive and needs an expert radiologist to report findings. Therefore, we conducted this study to determine an optimal cut-off value of ferritin in proportion to T2 MRI of liver and measurement of liver iron concentration for early detection of hepatic iron overload in Beta-thalassemia intermediate patients. METHODS This cross-sectional study was conducted on 108 patients with Beta-thalassemia intermediate who referred to tertiary hospital, Shiraz, Iran. Serum ferritin, hepatic T2 MRI, and liver iron concentration were assessed. Receiver operator characteristic was used to determine the sensitivity and specificity of cut-off value. RESULTS Serum ferritin levels showed a statistically significant negative correlation with T2 hepatic MRI (r = -0.290, p value =.003) and positive correlation with liver iron concentration (r = 0.426, p value <.001) in the patients with Beta-thalassemia intermediate. According to the receiver operator characteristic, the best cut-off value for ferritin to show early diagnosis of liver iron overload was 412 ng/mL. Calculated sensitivities and specificities were 0.78 and 0.82 for T2 MRI and 0.76 and 0.86 for liver iron concentration, respectively. CONCLUSION Serum ferritin levels of around 450 ng/mL might be considered as a cut-off point to evaluate hepatic iron overload before using expensive, not readily available T2 MRI. This level of serum ferritin could be considered for starting iron chelation therapy in patients with Beta-thalassemia intermediate in areas where T2 MRI is not available.
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Affiliation(s)
- Mehran Karimi
- a Hematology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Fatemeh Amirmoezi
- a Hematology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Sezaneh Haghpanah
- a Hematology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Seyedpouria Ostad
- b Radiology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Mehrzad Lotfi
- c Department of Radiology , Medical imaging research center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Sepideh Sefidbakht
- c Department of Radiology , Medical imaging research center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Shahed Rezaian
- b Radiology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
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16
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Maximova N, Gregori M, Boz G, Simeone R, Zanon D, Schillani G, Zennaro F. MRI-based evaluation of multiorgan iron overload is a predictor of adverse outcomes in pediatric patients undergoing allogeneic hematopoietic stem cell transplantation. Oncotarget 2017; 8:79650-79661. [PMID: 29108345 PMCID: PMC5668078 DOI: 10.18632/oncotarget.19021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/19/2017] [Indexed: 01/11/2023] Open
Abstract
The medical records of 44 pediatric patients who underwent allogeneic transplantation from 2011 to 2015 were retrospectively reviewed. Magnetic resonance imaging was used to measure iron concentrations in the liver, spleen, pancreas and bone. These patients were divided into two groups, 18 with non-elevated (< 100 μmol/g; Group 1) liver iron concentration before transplantation and 26 with elevated (> 100 μmol/g; Group 2) concentration . We compared transplant-related outcomes in the two groups. Iron overload was a negative prognostic risk factor for sinusoidal obstruction syndrome (OR = 17), osteoporosis (OR = 6.8), pancreatic insufficiency (OR = 17) and metabolic syndrome (OR = 15.1). No statistically significant differences in overall survival, disease-free survival, relapse incidence and incidence of acute or chronic graft-versus host disease were observed between the two groups. Mean times to engraftment of platelets (43.0 ± 35.3 days vs. 22.1 ± 9.5 days, p < 0.05) and neutrophils (23.1 ± 10.4 days vs. 17.8 ± 4.6 days, p < 0.05) appear significantly longer in Group 2 than in Group 1. Time to platelet engraftment showed statistically significant correlation with pre-transplant liver (r = 0.5775; p < 0.001) and bone iron concentration (r = 0.7305; p < 0.001). Post-transplant evaluation pointed out that iron concentration analyzed at the first follow-up peaked in all tissues. The iron accumulation was highest in bone, followed by the spleen, liver and pancreas. One year post transplant 9 of 18 (50%) patients in Group 1 and 6 of 22 (27%) in Group 2 presented with bone and/or spleen iron overload, but not with liver overload. Liver iron concentration is not always a reliable indicator of systemic siderosis or of the efficacy of chelation therapy.
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Affiliation(s)
- Natalia Maximova
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Massimo Gregori
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Boz
- University of Trieste, Piazzale Europa, 34128 Trieste, Italy
| | - Roberto Simeone
- Department of Transfusion Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Davide Zanon
- Pharmacy, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Giulia Schillani
- Bone Marrow Transplant Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Floriana Zennaro
- Department of Radiology, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
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T2* Magnetic Resonance Imaging Study of Pancreatic Iron Overload and its Relation With the Diabetic State in Thalassemic Patients. J Pediatr Hematol Oncol 2017; 39:337-340. [PMID: 28085743 DOI: 10.1097/mph.0000000000000767] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The present study was performed to evaluate pancreatic hemosiderosis by means of magnetic resonance imaging (MRI) T2* and its relation to the diabetic state in thalassemic patients. One hundred thirty transfusion-dependent thalassemic patients from Zafar adult thalassemia clinic, Tehran, Iran, were enrolled in the study. Data such as age, type of thalassemia, age at diagnosis, transfusion duration, ferritin level, and fasting blood sugar results were gathered. Pancreatic MRI T2* was performed for all patients. One hundred four thalassemic patients with no sign of diabetes mellitus and 26 thalassemic patients with diabetes mellitus entered the study. Out of a total of 130 patients, 102 had pancreatic hemosiderosis. Among them, 23 of 26 diabetic patients (88.5%) and 79 of 104 nondiabetic patients (76%) showed pancreatic hemosiderosis, indicating no statistically significant difference between the 2 groups. The mean pancreatic MRI T2* relaxation time for all patients was 13.99±12.43 ms. The mean relaxation was 13.62±8.38 and 14.08±13.28 ms for diabetic and nondiabetic patients, respectively, showing no statistical difference (P=0.202). In conclusion, we did not find a significant difference between diabetic and nondiabetic thalassemic patients regarding the MRI T2* relaxation time readings or the rate of pancreatic hemosiderosis. We recommend performing studies with a higher sample size and including patients from different age groups to further evaluate the role of T2* MRI of pancreatic iron overload and its relation with the diabetic state in thalassemic patients.
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Ben Salah N, Bou-Fakhredin R, Mellouli F, Taher AT. Revisiting beta thalassemia intermedia: past, present, and future prospects. ACTA ACUST UNITED AC 2017; 22:607-616. [PMID: 28589785 DOI: 10.1080/10245332.2017.1333246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The spectrum of thalassemias is wide ranging from thalassemia minor, which consists of mild hypochromic microcytic anemia without obvious clinical manifestations, to thalassemia major (TM), which is characterized by severe anemia since the first years of life and is transfusion dependent. Thalassemia intermedia (TI) describes those patients with mild or moderate anemia. OBJECTIVE To describe the genetic features and major clinical complications of TI, and the therapeutic approaches available in the management of this disease. METHODS Publications from potentially relevant journals were searched on Medline. RESULTS AND DISCUSSION Over the past decade, the understanding of TI has increased with regard to pathophysiology and molecular studies. It is now clear that clinical presentation and specific complications make TI different from TM. It is associated with greater morbidity, a wider spectrum of organ dysfunction and more complications than previously thought. CONCLUSION TI is not a mild disease. The interplay of three hallmark pathophysiologic factors (ineffective erythropoiesis, chronic anemia, and iron overload) leads to the clinical presentations seen in TI. New treatment modalities are currently being investigated to broaden the options available for TI management.
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Affiliation(s)
- Naouel Ben Salah
- a Faculty of Medicine Tunis , University Tunis El Manar , Tunis, Tunisia
| | - Rayan Bou-Fakhredin
- b Department of Internal Medicine , American University of Beirut Medical Center , Beirut , Lebanon
| | - Fethi Mellouli
- c Faculty of Medicine Tunis, National Center of Bone Marrow Graft , University Tunis El Manar , Tunis , Tunisia
| | - Ali T Taher
- b Department of Internal Medicine , American University of Beirut Medical Center , Beirut , Lebanon
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Hasiloglu ZI, Asik M, Ure E, Ertem F, Apak H, Albayram S. The utility of susceptibility-weighted imaging to evaluate the extent of iron accumulation in the choroid plexus of patients with β-thalassaemia major. Clin Radiol 2017; 72:903.e1-903.e7. [PMID: 28502664 DOI: 10.1016/j.crad.2017.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 12/20/2016] [Accepted: 04/11/2017] [Indexed: 01/09/2023]
Abstract
AIM To assess iron accumulation in the choroid plexus of β-thalassaemia patients using fast spin echo (FSE) T2-weighted, gradient echo (GRE) T2*-weighted, susceptibility-weighted imaging (SWI) and compare the results. MATERIALS AND METHODS Eighteen patients with transfusion-dependent β-thalassaemia and the control group underwent magnetic resonance imaging (MRI) examinations. Signal intensities were separately evaluated using a "number of hypointensity in the choroid plexus" (NHICP) grading system on axial FSE T2-weighted, GRE T2*-weighted, and SWI images. The NHICP grading system scores were compared using the chi-squared test. Spearman's correlation analysis was used to explore relationships between the variables and NHICP grading system scores. RESULTS The sensitivity of each technique was calculated: FSE T2-weighted imaging=0.17, GRE T2*-weighted imaging=0.48, and SWI=0.81. Three-sample test for equality of proportions showed that chi-squared=74.85, df=2, p<0.0001. All of the FSE T2-weighted, GRE T2*-weighted, and SWI images differed significantly in terms of their capacity to reveal iron accumulation in the choroid plexus. Of the three methods, SWI was the most sensitive. CONCLUSIONS SWI is useful for revealing iron deposition in the brains of β-thalassaemia patients, especially those in the early stages of disease, and it can be used to predict disease prognosis. The present study contributes to an understanding of the important role played by the choroid plexus in brain iron metabolism.
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Affiliation(s)
- Z I Hasiloglu
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey.
| | - M Asik
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - E Ure
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - F Ertem
- Istanbul University, Istanbul Medical School, Fatih, Istanbul, Turkey
| | - H Apak
- Department of Pediatrics, Division of Haematology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
| | - S Albayram
- Department of Radiology, Istanbul University, Cerrahpasa Medical School, Kocamustafapasa, Fatih, Istanbul, Turkey
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Barasch J, Hollmen M, Deng R, Hod EA, Rupert PB, Abergel RJ, Allred BE, Xu K, Darrah SF, Tekabe Y, Perlstein A, Wax R, Bruck E, Stauber J, Corbin KA, Buchen C, Slavkovich V, Graziano J, Spitalnik SL, Bao G, Strong RK, Qiu A. Disposal of iron by a mutant form of lipocalin 2. Nat Commun 2016; 7:12973. [PMID: 27796299 PMCID: PMC5095531 DOI: 10.1038/ncomms12973] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/22/2016] [Indexed: 01/19/2023] Open
Abstract
Iron overload damages many organs. Unfortunately, therapeutic iron chelators also have undesired toxicity and may deliver iron to microbes. Here we show that a mutant form (K3Cys) of endogenous lipocalin 2 (LCN2) is filtered by the kidney but can bypass sites of megalin-dependent recapture, resulting in urinary excretion. Because K3Cys maintains recognition of its cognate ligand, the iron siderophore enterochelin, this protein can capture and transport iron even in the acidic conditions of urine. Mutant LCN2 strips iron from transferrin and citrate, and delivers it into the urine. In addition, it removes iron from iron overloaded mice, including models of acquired (iron-dextran or stored red blood cells) and primary (Hfe−/−) iron overload. In each case, the mutants reduce redox activity typical of non-transferrin-bound iron. In summary, we present a non-toxic strategy for iron chelation and urinary elimination, based on manipulating an endogenous protein:siderophore:iron clearance pathway. Iron overload can be either hereditary or acquired via transfusions, and current treatments include the use of iron chelators that have adverse effects in some patients. Here the authors modify siderocalin to enhance iron excretion in urine, and demonstrate therapeutic efficacy in iron overload mouse models.
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Affiliation(s)
- Jonathan Barasch
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Maria Hollmen
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Rong Deng
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Eldad A Hod
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Peter B Rupert
- Fred Hutchinson Cancer Research Center, Basic Sciences Division, University of Washington School of Medicine Biochemistry, Immunology, Mail Stop A3-025, Seattle, Washington 98109, USA
| | - Rebecca J Abergel
- Lawrence Berkeley National Laboratory, Chemical Sciences Division, BioActinide Chemistry Group, MS 70A-1150, One Cyclotron Road, Berkeley, California 94720, USA
| | - Benjamin E Allred
- Lawrence Berkeley National Laboratory, Chemical Sciences Division, BioActinide Chemistry Group, MS 70A-1150, One Cyclotron Road, Berkeley, California 94720, USA
| | - Katherine Xu
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Shaun F Darrah
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Yared Tekabe
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Alan Perlstein
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Rebecca Wax
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Efrat Bruck
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Jacob Stauber
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Kaitlyn A Corbin
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Charles Buchen
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Vesna Slavkovich
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Joseph Graziano
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Steven L Spitalnik
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA
| | - Guanhu Bao
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea and Food Sciences, Anhui Agricultural University, 130 Changjiang West Road, Hefei 230036, China
| | - Roland K Strong
- Fred Hutchinson Cancer Research Center, Basic Sciences Division, University of Washington School of Medicine Biochemistry, Immunology, Mail Stop A3-025, Seattle, Washington 98109, USA
| | - Andong Qiu
- Columbia University, Russ Berrie Medical Science Pavilion, 1150 Saint Nicholas Avenue, Rm 411, New York, New York 10032, USA.,Columbia University, New York &Tongji University, School of Life Sciences and Technology, 1239 Siping Road, Shanghai 200092, China
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21
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Akhtar IK, Ashraf M, Khalid IU, Hussain M. Surgical outcome of spelenectomy in Thalassemia major in children. Pak J Med Sci 2016; 32:305-8. [PMID: 27182228 PMCID: PMC4859011 DOI: 10.12669/pjms.322.8815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective: To determine the surgical outcome of splenectomy in children with thalassemia major. Methods: It is an observational and descriptive study conducted in Department of Paediatric Surgery in collaboration with hematology, radiology, anesthesia and paediatric intensive care department at The Children’s Hospital and the Institute of Child Health, Multan during the period of September 2007 to September 2013. A total of 50 patients suffering from thalassemia major already diagnosed and under management reffered from haematology department for splenectomy were included in this study. After admission, patients were assessed on the basis of history, clinical examination, and necessary investigations before surgery and later on follow-up. Investigations carried were CBC, PT, APTT, Viral markers, ECG, X-ray Chest, abdominal ultrasonography and ECHO if necessary. Splenectomy was performed after prophylactic vaccination against post splenectomy infections. Follow up was performed for at least two years. Blood transfusion requirements and number of hospital visits per annum before and after splenectomy were calculated and results analyzed statistically using SPSS-20. Results: Fifty patients were included in this study. Out of these fifty, 43 (86%) male and 7(14%) were female with a mean age of 9 years. Average blood transfusion requirement was 250 ml/kg/year, interval of blood transfusion was two weeks and twenty five visits per year before splenectomy. After splenectomy, requirement of blood transfusion reduced to 125ml/kg/year, interval between transfusion increased to one month and hospital visits reduced up to twelve per year. Conclusion: Blood transfusion requirement and number of hospital visits per year are decreased and interval between transfusions is increased after splenectomy. Splenectomy should not be delayed when indicated. Preoperative vaccination decreases the chance of post splenectomy infection.
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Affiliation(s)
- Ikramullah Khan Akhtar
- Ikramullah Khan Akhtar, Paediatric Surgery Department, Children's Hospital & Institute of Child Health, Multan, Pakistan
| | - Muhammad Ashraf
- Muhammad Ashraf, Paediatric Surgery Department, Children's Hospital & Institute of Child Health, Multan, Pakistan
| | - Irum Uzma Khalid
- Irum Uzma Khalid, Paediatric Surgery Department, Children's Hospital & Institute of Child Health, Multan, Pakistan
| | - Mukhtar Hussain
- Mukhtar Hussain, Paediatric Surgery Department, Children's Hospital & Institute of Child Health, Multan, Pakistan
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22
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Gutiérrez L, House MJ, Vasavda N, Drašar E, Gonzalez-Gascon y Marin I, Kulasekararaj AG, St Pierre TG, Thein SL. Tissue Iron Distribution Assessed by MRI in Patients with Iron Loading Anemias. PLoS One 2015; 10:e0139220. [PMID: 26406992 PMCID: PMC4583270 DOI: 10.1371/journal.pone.0139220] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/09/2015] [Indexed: 12/31/2022] Open
Abstract
Bone marrow, spleen, liver and kidney proton transverse relaxation rates (R2), together with cardiac R2* from patients with sickle cell disease (SCD), paroxysmal nocturnal hemoglobinuria (PNH) and non-transfusion dependent thalassemia (NTDT) have been compared with a control group. Increased liver and bone marrow R2 values for the three groups of patients in comparison with the controls have been found. SCD and PNH patients also present an increased spleen R2 in comparison with the controls. The simultaneous measurement of R2 values for several tissue types by magnetic resonance imaging (MRI) has allowed the identification of iron distribution patterns in diseases associated with iron imbalance. Preferential liver iron loading is found in the highly transfused SCD patients, while the low transfused ones present a preferential iron loading of the spleen. Similar to the highly transfused SCD group, PNH patients preferentially accumulate iron in the liver. A reduced spleen iron accumulation in comparison with the liver and bone marrow loading has been found in NTDT patients, presumably related to the differential increased intestinal iron absorption. The correlation between serum ferritin and tissue R2 is moderate to good for the liver, spleen and bone marrow in SCD and PNH patients. However, serum ferritin does not correlate with NTDT liver R2, spleen R2 or heart R2*. As opposed to serum ferritin measurements, tissue R2 values are a more direct measurement of each tissue's iron loading. This kind of determination will allow a better understanding of the different patterns of tissue iron biodistribution in diseases predisposed to tissue iron accumulation.
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Affiliation(s)
- Lucía Gutiérrez
- Instituto de Ciencia de Materiales de Madrid, ICMM-CSIC, Cantoblanco, Madrid, Spain
- School of Physics, The University of Western Australia, Crawley, WA, Australia
- * E-mail:
| | - Michael J. House
- School of Physics, The University of Western Australia, Crawley, WA, Australia
| | - Nisha Vasavda
- King’s College London, Faculty of Life Sciences & Medicine, Molecular Haematology, London, United Kingdom
| | - Emma Drašar
- King’s College London, Faculty of Life Sciences & Medicine, Molecular Haematology, London, United Kingdom
- King’s College Hospital NHS Foundation Trust, Department of Haematology, London, United Kingdom
| | - Isabel Gonzalez-Gascon y Marin
- King’s College London, Faculty of Life Sciences & Medicine, Molecular Haematology, London, United Kingdom
- Hospital Infanta Leonor, Department of Haematology, Madrid, Spain
| | - Austin G. Kulasekararaj
- King’s College London, Faculty of Life Sciences & Medicine, Molecular Haematology, London, United Kingdom
- King’s College Hospital NHS Foundation Trust, Department of Haematology, London, United Kingdom
| | - Tim G. St Pierre
- School of Physics, The University of Western Australia, Crawley, WA, Australia
| | - Swee L. Thein
- King’s College London, Faculty of Life Sciences & Medicine, Molecular Haematology, London, United Kingdom
- King’s College Hospital NHS Foundation Trust, Department of Haematology, London, United Kingdom
- NHLB/ NIH, Sickle Cell Branch, Bethesda, MD 20892, United States of America
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İdilman İS, Gümrük F, Haliloğlu M, Karçaaltıncaba M. The Feasibility of Magnetic Resonance Imaging for Quantification of Liver, Pancreas, Spleen, Vertebral Bone Marrow, and Renal Cortex R2* and Proton Density Fat Fraction in Transfusion-Related Iron Overload. Turk J Haematol 2015; 33:21-7. [PMID: 26376710 PMCID: PMC4805342 DOI: 10.4274/tjh.2015.0142] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE We aimed to evaluate the feasibility of quantification of liver, pancreas, spleen, vertebral bone marrow, and renal cortex R2* and magnetic resonance imaging-proton density fat fraction (MRI-PDFF) and to evaluate the correlations among them in patients with transfusion-related iron overload. MATERIALS AND METHODS A total of 9 patients (5 boys, 4 girls) who were referred to our clinic with suspicion of hepatic iron overload were included in this study. All patients underwent T1-independent volumetric multi-echo gradient-echo imaging with T2* correction and spectral fat modeling. MRI examinations were performed on a 1.5 T MRI system. RESULTS All patients had hepatic iron overload. Severe hepatic iron overload was recorded in 5/9 patients (56%), and when we evaluated the PDFF maps of these patients, we observed an extensive patchy artifact in the liver in 4 of 5 patients (R2* greater than 671 Hz). When we performed MRI-PDFF measurements despite these artifacts, we observed artifactual high MRI-PDFF values. There was a close correlation between average pancreas R2* and average pancreas MRI-PDFF (p=0.003, r=0.860). There was a significant correlation between liver R2* and average pancreas R2* (p=0.021, r=0.747), liver R2* and renal cortex R2* (p=0.020, r=0.750), and average pancreas R2* and renal cortex R2* (p=0.003, r=0.858). There was a significant negative correlation between vertebral bone marrow R2* and age (p=0.018, r=-0.759). CONCLUSION High iron content of the liver, especially with a T2* value shorter than the first echo time can spoil the efficacy of PDFF calculation. Fat deposition in the pancreas is accompanied by pancreatic iron overload. There is a significant correlation between hepatic siderosis and pancreatic siderosis. Renal cortical and pancreatic siderosis are correlated, too.
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Endocrine and bone complications in β-thalassemia intermedia: current understanding and treatment. BIOMED RESEARCH INTERNATIONAL 2015; 2015:813098. [PMID: 25834825 PMCID: PMC4365366 DOI: 10.1155/2015/813098] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 09/15/2014] [Accepted: 10/07/2014] [Indexed: 01/19/2023]
Abstract
Thalassemia intermedia (TI), also known as nontransfusion dependent thalassemia (NTDT), is a type of thalassemia where affected patients do not require lifelong regular transfusions for survival but may require occasional or even frequent transfusions in certain clinical settings and for defined periods of time. NTDT encompasses three distinct clinical forms: β-thalassemia intermedia (β-TI), Hb E/β-thalassemia, and α-thalassemia intermedia (Hb H disease). Over the past decade, our understanding of the molecular features, pathophysiology, and complications of NTDT particularly β-TI has increased tremendously but data on optimal treatment of disease and its various complications are still lacking. In this paper, we shall review a group of commonly encountered complications in β-TI, mainly endocrine and bone complications.
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25
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Isik P, Yarali N, Tavil B, Demirel F, Karacam GB, Sac RU, Fettah A, Ozkasap S, Kara A, Tunc B. Endocrinopathies in Turkish children with Beta thalassemia major: results from a single center study. Pediatr Hematol Oncol 2014; 31:607-15. [PMID: 24854890 DOI: 10.3109/08880018.2014.898724] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The endocrinological complications in β-thalassemia major patients do affect the life quality to a large extend. In this study, the endocrinological complications of 47 β-thalassemia patients, who have been followed-up at our hospital's pediatric hematology department, were evaluated. Out of β-thalassemia major cases included to this study, the 55.3% was male and 44.7% was female. The patients' mean levels of ferritin, whose mean age was 10.0 ± 4.5 years (2-20 years), were 2497 ± 1469 ng/mL (472-8558 ng/mL). At least one endocrinological pathology in 27 out of 47 (57.4%) and more than one endocrinological pathology in 14 out of 47 (29.7%) thalassemia patients were observed. The most frequently observed complication in followed-up cases was vitamin D insufficiency and deficiency (78.2%). The other complications in decreasing order were pubertal failure (41.6%), growth retardation (25.5%), decreased bone-mineral density (22.2%), secondary hyperparathyroidism (11.5%), overt hypothyroidism (4.25%), subclinical hypothyroidism (2.12%), and impaired glucose tolerance (2.12%). There was no statistically significant difference between serum mean ferritin level and endocrin complications (P > .05). Four patients (8.5%) had decreased signal intensity in pituitary magnetic resonance imaging (MRI) but this finding was not associated with ferritin levels (P = .87). MRI parameters were similar between patients with and without gonadal dysfunction. Mean height of the pituitary gland was 4.98 ± 1.1 mm (3-9 mm) and this was similar to those normal values in the literature. Ferritin levels were not correlated with pituitary height (P > .05). Beta thalassemia major, having the potential of leading to multisystemic complications, is a chronic disease that should be treated and followed-up by a multidisciplinary approach. Due to frequently encountered endocrinological complications, beta thalassemic patients should be followed-up regularly by hematology and endocrinology departments in coordination.
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Affiliation(s)
- Pamir Isik
- 1Department of Pediatric Hematology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
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26
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Pfeifer CD, Schoennagel BP, Grosse R, Wang ZJ, Graessner J, Nielsen P, Adam G, Fischer R, Yamamura J. Pancreatic iron and fat assessment by MRI-R2* in patients with iron overload diseases. J Magn Reson Imaging 2014; 42:196-203. [PMID: 25236606 DOI: 10.1002/jmri.24752] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 08/28/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND To determine the pancreatic iron (R2*) and fat content (FC) in comparison to hepatic and cardiac R2* in patients with iron overload disorders like β-thalassemia major (TM), Diamond-Blackfan anemia (DBA) or hereditary hemochromatosis. METHODS R2* rates were assessed in the liver, heart and pancreas of 42 patients with TM, 29 subjects with other iron overload diseases, and 10 controls using an ECG-gated breathhold sequence (12 echo time [TE] = 1.3-25.7 ms, readout repetition time [TR] = 244 ms). Pancreatic R2* and FC were assessed from TE dependent region of interest based signal intensities performing water-fat chemical shift relaxometry and were compared with laboratory parameters (glucose, HbA1c, amylase and lipase). RESULTS A pancreatic iron gradient from tail (R2* = 122 s(-1) ) to head (R2* = 114 s(-1) , P < 10(-4) ) was found. The close association between cardiac and pancreatic R2* was also confirmed in patients with TM and other iron overload diseases (rs = 0.64, P < 10(-4) ). Receiver operator characteristic analysis (area: 0.89, P < 10(-4) ) identified patients with elevated cardiac iron at a pancreatic R2* cut-off level of 131s(-1) (sensitivity = specificity at 81%). Highest pancreatic R2* (211s(-1) ) and FC (36%) were found in the tail region of diabetic patients with TM. CONCLUSION Pancreatic tail showed highest R2* rates and fat contents, especially in patients with thalassemia. Besides iron accumulation fatty degeneration might be an additional risk factor for the development of diabetes in β-thalassemia major, but this hypothesis needs further studies in prediabetic patients.
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Affiliation(s)
- Charlotte D Pfeifer
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Bjoern P Schoennagel
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Regine Grosse
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Germany
| | - Zhiyue J Wang
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Peter Nielsen
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Roland Fischer
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Germany.,UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Jin Yamamura
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Germany
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27
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Li MJ, Peng SSF, Lu MY, Chang HH, Yang YL, Jou ST, Lin DT, Lin KH. Diabetes mellitus in patients with thalassemia major. Pediatr Blood Cancer 2014; 61:20-4. [PMID: 24115521 DOI: 10.1002/pbc.24754] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/05/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diabetes mellitus is a major endocrinopathy for patients with thalassemia major. Although diabetes mellitus is multifactorial, iron loading is its primary cause and its management poses a clinical challenge. Detecting the pre-diabetes stage is critical because clinical diabetes can potentially be reversed or prevented. PROCEDURE Patients with thalassemia major who received regular blood transfusion therapy from 1994 to 2010 were evaluated for the incidence of diabetes mellitus and glucose dysregulation. The association between patients' clinical, biochemical, and image parameters was also evaluated. RESULTS The patients with diabetes were significantly older, had higher ferritin levels, a smaller pancreas volume, and lower cardiac T2* magnetic resonance imaging (MRI) values than the patients without diabetes. The pancreas T2* MRI values were higher in the patients without diabetes, but the difference was not statistically significant. The liver iron concentration did not differ between the patients with and without diabetes. The prevalence of hepatitis C infection and hypogonadism was also higher in the patients with diabetes. In the patients without diabetes, the cardiac T2* MRI values were higher in patients with normal fasting glucose levels (P = 0.03), and the homeostasis model assessment of insulin resistance level was associated with hepatitis C infection (P = 0.024, r = 0.32) and hypogonadism (P = 0.034, r = 0.301). CONCLUSIONS Fasting glucose and insulin levels were appropriate screening tools for evaluating glucose dysregulation and complemented the MRI findings. The cardiac T2* and pancreas volumes were significant predictors of diabetes.
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Affiliation(s)
- Meng-Ju Li
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
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28
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Cheng HLM, Stikov N, Ghugre NR, Wright GA. Practical medical applications of quantitative MR relaxometry. J Magn Reson Imaging 2013; 36:805-24. [PMID: 22987758 DOI: 10.1002/jmri.23718] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Conventional MR images are qualitative, and their signal intensity is dependent on several complementary contrast mechanisms that are manipulated by the MR hardware and software. In the absence of a quantitative metric for absolute interpretation of pixel signal intensities, one that is independent of scanner hardware and sequences, it is difficult to perform comparisons of MR images across subjects or longitudinally in the same subject. Quantitative relaxometry isolates the contributions of individual MR contrast mechanisms (T1, T2, T2) and provides maps, which are independent of the MR protocol and have a physical interpretation often expressed in absolute units. In addition to providing an unbiased metric for comparing MR scans, quantitative relaxometry uses the relationship between MR maps and physiology to provide a noninvasive surrogate for biopsy and histology. This study provides an overview of some promising clinical applications of quantitative relaxometry, followed by a description of the methods and challenges of acquiring accurate and precise quantitative MR maps. It concludes with three case studies of quantitative relaxometry applied to studying multiple sclerosis, liver iron, and acute myocardial infarction.
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Affiliation(s)
- Hai-Ling Margaret Cheng
- Physiology and Experimental Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
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Berdoukas V, Farmaki K, Carson S, Wood J, Coates T. Treating thalassemia major-related iron overload: the role of deferiprone. J Blood Med 2012; 3:119-29. [PMID: 23112580 PMCID: PMC3480237 DOI: 10.2147/jbm.s27400] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Over the last 20 years, management for thalassemia major has improved to the point where we predict that patients’ life expectancy will approach that of the normal population. These outcomes result from safer blood transfusions, the availability of three iron chelators, new imaging techniques that allow specific organ assessment of the degree of iron overload, and improvement in the treatment of hepatitis. In October 2011, the Food and Drug Administration licensed deferiprone, further increasing the available choices for iron chelation in the US. The ability to prescribe any of the three chelators as well as their combinations has led to more effective reduction of total body iron. The ability to determine the amount of iron in the liver and heart by magnetic resonance imaging allows the prescription of the most appropriate chelation regime for patients and to reconsider what our aims with respect to total body iron should be. Recent evidence from Europe has shown that by normalizing iron stores not only are new morbidities prevented but also reversal of many complications such as cardiac failure, hypothyroidism, hypogonadism, impaired glucose tolerance, and type 2 diabetes can occur, improving survival and patients’ quality of life. The most effective way to achieve normal iron stores seems to be with the combination of deferoxamine and deferiprone. Furthermore, outcomes should continue to improve in the future. Starting relative intensive chelation in younger children may prevent short stature and abnormal pubertal maturation as well as other iron-related morbidities. Also, further information should become available on the use of other combinations in chelation treatment, some of which have been used only in a very limited fashion to date. All these advances in management require absolute cooperation and understanding of parents, children, and, subsequently, the patients themselves. Only with such cooperation can normal long-term survival be achieved, as adherence to treatment is now likely the primary barrier to longevity.
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Affiliation(s)
- Vasilios Berdoukas
- Division of Hematology/Oncology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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30
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de Assis RA, Ribeiro AAF, Kay FU, Rosemberg LA, Nomura CH, Loggetto SR, Araujo AS, Fabron Junior A, de Almeida Veríssimo MP, Baldanzi GR, Espósito BP, Baroni RH, Wood JC, Hamerschlak N. Pancreatic iron stores assessed by magnetic resonance imaging (MRI) in beta thalassemic patients. Eur J Radiol 2012; 81:1465-70. [DOI: 10.1016/j.ejrad.2011.03.077] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 03/23/2011] [Accepted: 03/24/2011] [Indexed: 11/24/2022]
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Papakonstantinou O, Foufa K, Benekos O, Alexopoulou E, Mademli M, Balanika A, Economopoulos N, Kelekis NL. Use of fat suppression in R₂ relaxometry with MRI for the quantification of tissue iron overload in beta-thalassemic patients. Magn Reson Imaging 2012; 30:926-33. [PMID: 22495242 DOI: 10.1016/j.mri.2012.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 02/22/2012] [Accepted: 03/01/2012] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the performance and results of R(2) relaxometry using a fat-suppressed (FS) multiecho sequence and compare these to conventional R(2) relaxometry in estimating tissue iron overload. MATERIALS AND METHODS Relaxation rate values (R(2)=1/T2) of the liver, spleen, pancreas and vertebral bone marrow (VBM) were estimated in 21 patients with β-thalassemia major, using a respiratory-triggered 16-echo Carr-Purcell-Meiboom-Gill (CPMG) spin-echo sequence before (R(2)) and after (R(2) FS) the application of chemically selective fat suppression. RESULTS Hepatic and splenic R(2) FS values correlated with respective R(2) values (r=0.98 and r=0.96, P<.001), whereas correlations between R(2) FS and R(2) values for pancreas and VBM were not statistically significant. Bland-Altman plots show disagreement between R(2) and R(2) FS values, particularly for pancreas and VBM. Hepatic, pancreatic and VBM R(2) FS values correlated with serum ferritin (r=0.88, P<.001; r=0.51, P<.003; and r=0.75, P<.002, respectively). Hepatic R(2) FS values correlated with splenic R(2) FS (r=0.77, P<.03), pancreatic R(2) FS (r=0.61, P<.006) and VBM R(2) FS values (r=0.70, P<.001), whereas pancreatic R(2) FS values correlated also with VMB R(2) FS values. On the contrary, among the R(2) values of the above tissues, obtained without fat suppression, only hepatic R(2) values correlated with serum ferritin, whereas no correlation was documented between hepatic and pancreatic or VBM R(2) values. The application of fat suppression did not improve breathing or flow artifacts. CONCLUSION Application of fat suppression in the standard CPMG sequence improved the capability of MRI in noninvasive quantification of iron, particularly in lipid-rich tissues, such as vertebral bone marrow (VBM) and pancreas.
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Noetzli LJ, Panigrahy A, Mittelman SD, Hyderi A, Dongelyan A, Coates TD, Wood JC. Pituitary iron and volume predict hypogonadism in transfusional iron overload. Am J Hematol 2012; 87:167-71. [PMID: 22213195 DOI: 10.1002/ajh.22247] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/02/2011] [Indexed: 11/10/2022]
Abstract
Hypogonadism is the most common morbidity in patients with transfusion-dependent anemias such as thalassemia major. We used magnetic resonance imaging (MRI) to measure pituitary R2 (iron) and volume to determine at what age these patients develop pituitary iron overload and volume loss. We recruited 56 patients (47 with thalassemia major, five with chronically transfused thalassemia intermedia and four with Blackfan-Diamond syndrome) to have pituitary MRIs to measure pituitary R2 and volume. Hypogonadism was defined clinically based on the timing of secondary sexual characteristics or the need for sex hormone replacement therapy. Patients with transfusional iron overload begin to develop pituitary iron overload in the first decade of life; however, clinically significant volume loss was not observed until the second decade of life. Severe pituitary iron deposition (Z > 5) and volume loss (Z < -2.5) were independently predictive of hypogonadism. Pituitary R2 correlated significantly with serum ferritin as well as liver, pancreatic, and cardiac iron deposition by MRI. Log pancreas R2* was the best single predictor for pituitary iron, with an area under the receiving operator characteristic curve of 0.88, but log cardiac R2* and ferritin were retained on multivariate regression with a combined r(2) of 0.71. Pituitary iron overload and volume loss were independently predictive of hypogonadism. Many patients with moderate-to-severe pituitary iron overload retained normal gland volume and function, representing a potential therapeutic window. The subset of hypogonadal patients having preserved gland volumes may also explain improvements in pituitary function observed following intensive chelation therapy.
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Affiliation(s)
- Leila J Noetzli
- Department of Pediatrics, Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
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33
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Margariti PN, Astrakas LG, Tsouli SG, Hadjigeorgiou GM, Konitsiotis S, Argyropoulou MI. Investigation of unmedicated early onset restless legs syndrome by voxel-based morphometry, T2 relaxometry, and functional MR imaging during the night-time hours. AJNR Am J Neuroradiol 2011; 33:667-72. [PMID: 22173758 DOI: 10.3174/ajnr.a2829] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE The pathophysiology of eRLS has not yet been elucidated. The purpose of the study was to assess, in patients with eRLS, the volume, iron content, and activation of the brain during night-time episodes of SLD and PLMs. MATERIALS AND METHODS Eleven right-handed unmedicated patients with eRLS (mean age, 55.3 ± 8.4 years; disease duration, 17.5 ± 14.05 years) and 11 matched control subjects were studied with a T1-weighted high-resolution 3D spoiled gradient-echo sequence used for VBM and a multisection spin-echo T2-weighted sequence used for T2 relaxometry. Additionally, a single-shot multisection gradient echo-planar sequence was used for fMRI. Brain activation was recorded during spontaneous SLD and PLMs. SPM software was used for analysis of the functional data. RESULTS The patients showed no regional brain volume change, but T2 relaxometry revealed decreased T2 relaxation time in the right globus pallidus internal and the STN, indicating increased iron content. The patients were observed to activate the following areas: in the left hemisphere, the primary motor and somatosensory cortex, the thalamus, the pars opercularis, and the ventral anterior cingulum; and in the right hemisphere, the striatum, the inferior and superior parietal lobules, and the dorsolateral prefrontal cortex. Bilateral activation was observed in the cerebellum, the midbrain, and the pons. CONCLUSIONS eRLS is associated with increased iron content of the globus pallidus internal and STN, suggesting dysfunction of the basal ganglia. Activation of the striatofrontolimbic area may represent the neurofunctional substrate mediating the repetitive compulsive movements seen in RLS.
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Affiliation(s)
- P N Margariti
- Department of Radiology, Medical School, University of Ioannina, Ioannina, Greece
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34
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Quantitative T2* Magnetic Resonance Imaging for Evaluation of Iron Deposition in the Brain of β-Thalassemia Patients. Clin Neuroradiol 2011; 22:211-7. [DOI: 10.1007/s00062-011-0108-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 10/17/2011] [Indexed: 10/14/2022]
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Noetzli LJ, Panigrahy A, Hyderi A, Dongelyan A, Coates TD, Wood JC. Pituitary iron and volume imaging in healthy controls. AJNR Am J Neuroradiol 2011; 33:259-65. [PMID: 22081683 DOI: 10.3174/ajnr.a2788] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients with transfusional iron overload develop iron deposits in the pituitary gland, which are associated with volume loss and HH. The purpose of this study was to characterize R2 and volumetric data in a healthy population for diagnostic use in patients with transfusional iron overload. MATERIALS AND METHODS One hundred healthy controls without iron overload between the ages of 2 and 48 were recruited to have MR imaging of the brain to assess their pituitary R2 and volume. Pituitary R2 was assessed with a 8-echo spin-echo sequence, and pituitary volumes, by a 3D spoiled gradient-echo sequence with 1-mm(3) resolution. A 2-component continuous piecewise linear approximation was used for creating volumetric and R2 nomograms. Equations were generated from regression relationships for convenient z-score calculation. RESULTS Pituitary R2 rose weakly with age (r(2) = 0.19, P < .0001). Anterior and total pituitary volumes increased steadily up to 18 years of age, after which volume slightly decreased. Females had larger pituitary glands, most likely representing their larger lactotroph population. CONCLUSIONS From these data, a clinician can calculate the z scores for R2 and pituitary volume in patients with iron overload. Normal ranges are well-differentiated from values previously associated with endocrine disease in transfusional siderosis; this finding suggests that preclinical iron overload can be recognized and appropriately treated.
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Affiliation(s)
- L J Noetzli
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California 90027, USA
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Yamamura J, Grosse R, Jarisch A, Janka GE, Nielsen P, Adam G, Fischer R. Pancreatic exocrine function and cardiac iron in patients with iron overload and with thalassemia. Pediatr Blood Cancer 2011; 57:674-6. [PMID: 21671371 DOI: 10.1002/pbc.22990] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Accepted: 11/30/2010] [Indexed: 12/25/2022]
Abstract
Patients with β-thalassemia major at risk of cardiac iron overload have to be identified to undergo myocardial iron measurements by magnetic resonance imaging (MRI), especially, in areas and centers with restricted access to MRI. Measurements of heart iron, liver iron, and pancreatic exocrine function were performed in 44 patients by MRI-R2* [the transverse relaxation rate R2* (= 1/T2*) characterizes the magnetic resonance decay from protons not being in phase with each other in contrast to R2 (= 1/T2)], biomagnetic liver susceptometry (LIC), and pancreatic serum amylase (PAM) and lipase (LIP), respectively. ROC analysis (area: 0.88) for detecting patients with cardiac R2* > 50 sec(-1) (T2* < 20 msec) by LIP revealed a cut-off level of 19 U/L. In conclusion, patients at risk of elevated cardiac iron levels could be identified by the exocrine pancreatic lipase and amylase function parameters.
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Affiliation(s)
- Jin Yamamura
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Vag T, Kentouche K, Krumbein I, Reichenbach JR, Lopatta E, Renz DM, Stenzel M, Beck J, Kaiser WA, Mentzel HJ. Noninvasive measurement of liver iron concentration at MRI in children with acute leukemia: initial results. Pediatr Radiol 2011; 41:980-4. [PMID: 21674286 DOI: 10.1007/s00247-011-2122-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 01/06/2011] [Accepted: 01/17/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Routine assessment of body iron load in patients with acute leukemia is usually done by serum ferritin (SF) assay; however, its sensitivity is impaired by different conditions including inflammation and malignancy. OBJECTIVE To estimate, using MRI, the extent of liver iron overload in children with acute leukemia and receiving blood transfusions, and to examine the association between the degree of hepatic iron overload and clinical parameters including SF and the transfusion iron load (TIL). MATERIAL AND METHODS A total of 25 MRI measurements of the liver were performed in 15 children with acute leukemia (mean age 9.75 years) using gradient-echo sequences. Signal intensity ratios between the liver and the vertebral muscle (L/M ratio) were calculated and compared with SF-levels. TIL was estimated from the cumulative blood volume received, assuming an amount of 200 mg iron per transfused red blood cell unit. RESULTS Statistical analysis revealed good correlation between the L/M SI ratio and TIL (r = -0.67, P = 0.002, 95% confidence interval CI = -0.83 to -0.34) in patients with acute leukemia as well as between L/M SI ratio and SF (r = -0.76, P = 0.0003, 95% CI = -0.89 to -0.52). CONCLUSION SF may reliably reflect liver iron stores as a routine marker in patients suffering from acute leukemia.
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Affiliation(s)
- Tibor Vag
- Institute of Diagnostic and Interventional Radiology, Friedrich Schiller University Jena, Jena, Germany.
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Gautier A, Lainé F, Massart C, Sandret L, Piguel X, Brissot P, Balkau B, Deugnier Y, Bonnet F. Liver iron overload is associated with elevated SHBG concentration and moderate hypogonadotrophic hypogonadism in dysmetabolic men without genetic haemochromatosis. Eur J Endocrinol 2011; 165:339-43. [PMID: 21646287 DOI: 10.1530/eje-11-0215] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To assess the relation between moderate iron overload on sex hormone binding globulin (SHBG) levels and gonadotroph function in men with dysmetabolic iron overload syndrome and the effects of phlebotomy. METHODS The relationship between magnetic resonance imaging assessed liver iron concentration (LIC) and plasma ferritin levels with total testosterone, bioavailable testosterone (BT), SHBG and LH levels, were studied in 50 men with moderate dysmetabolic iron excess, in the absence of genetic haemochromatosis, who were randomised to phlebotomy therapy or to normal care. RESULTS Four patients (8%) had low total testosterone (<10.4 nmol/l) and 13 patients (26%) had low BT (<2.5 nmol/l). In the entire population, those with LIC above the median (90 μmol/l) had a higher mean SHBG (P=0.028), lower LH (P=0.039) than those with LIC below the median. In multivariable analysis (adjusted for age, and fasting insulin) LIC was significantly associated with SHBG (positively) and LH (negatively). Patients in the highest quartile of SHBG had higher LIC (P=0.010) and higher ferritinaemia (P=0.012) than those in the three other quartiles. Iron depletion by venesection did not significantly improve any hormonal levels. CONCLUSIONS Hypogonadism is not infrequent in men with dysmetabolic iron overload syndrome. Liver iron excess is associated with increased plasma SHBG and moderate hypogonadotrophic hypogonadism. Phlebotomy therapy needs further investigation in symptomatic hypogonadal men with dysmetabolic iron excess.
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Affiliation(s)
- Alain Gautier
- Service d'Endocrinologie, CHU de Rennes, Université Rennes 1, Hôpital Sud, 16 Boulevard de Bulgarie, 35203 Rennes, France.
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Assis RAD, Kay FU, Rosemberg LA, Parma AHC, Nomura CH, Loggetto SR, Araujo ADS, Fabron Junior A, Veríssimo MPDA, Baldanzi GR, Steagal MA, Velloso CAGDS, Espósito BP, Nakashima SS, Diniz MDS, Tricta F, Baroni RH, Funari MBDG, Wood JC, Ribeiro AAF, Hamerschlak N. Iron overload in Brazilian thalassemic patients. EINSTEIN-SAO PAULO 2011; 9:165-72. [DOI: 10.1590/s1679-45082011ao1897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
ABSTRACT Objectives: To evaluate the use of magnetic resonance imaging in patients with β-thalassemia and to compare T2* magnetic resonance imaging results with serum ferritin levels and the redox active fraction of labile plasma iron. Methods: We have retrospectively evaluated 115 chronically transfused patients (65 women). We tested serum ferritin with chemiluminescence, fraction of labile plasma iron by cellular fluorescence and used T2* MRI to assess iron content in the heart, liver, and pancreas. Hepatic iron concentration was determined in liver biopsies of 11 patients and the results were compared with liver T2* magnetic resonance imaging. Results: The mean serum ferritin was 2,676.5 +/- 2,051.7 ng/mL. A fraction of labile plasma iron was abnormal (> 0,6 Units/mL) in 48/83 patients (57%). The mean liver T2* value was 3.91 ± 3.95 ms, suggesting liver siderosis in most patients (92.1%). The mean myocardial T2* value was 24.96 ± 14.17 ms and the incidence of cardiac siderosis (T2* < 20 ms) was 36%, of which 19% (22/115) were severe cases (T2* < 10 ms). The mean pancreas T2* value was 11.12 ± 11.20 ms, and 83.5% of patients had pancreatic iron deposition (T2* < 21 ms). There was significant curvilinear and inverse correlation between liver T2* magnetic resonance imaging and hepatic iron concentration (r= −0.878; p < 0.001) and moderate correlation between pancreas and myocardial T2* MRI (r = 0.546; p < 0.0001). Conclusion: A high rate of hepatic, pancreatic and cardiac impairment by iron overload was demonstrated. Ferritin levels could not predict liver, heart or pancreas iron overload as measured by T2* magnetic resonance imaging. There was no correlation between liver, pancreas, liver and myocardial iron overload, neither between ferritin and fraction of labile plasma iron with liver, heart and pancreas T2* values
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - John C. Wood
- Childrens Hospital of Los Angeles, Estados Unidos
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Berdoukas V, Farmaki K, Wood JC, Coates T. Iron chelation in thalassemia: time to reconsider our comfort zones. Expert Rev Hematol 2011; 4:17-26. [PMID: 21322775 DOI: 10.1586/ehm.10.74] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Over the last 20 years, the management of thalassemia major has improved to the point where we predict that the patients' life expectancy will approach that of the normal population. These outcomes result from safer blood transfusions, the availability of three iron chelators, new imaging techniques that allow organ-specific assessment of the degree of iron overload and improvement in the treatment of hepatitis. The ability to prescribe any of the three chelators, as well as their combinations, has led to a more effective reduction of the total body iron. The ability to determine the amount of iron in the liver and heart by MRI has allowed the prescription of the most appropriate chelation regime for the patient and has allowed the reconsideration of 'the comfort zones'. Thus, normalizing iron stores not only prevents new morbidities but also reverses many complications, such as cardiac failure, hypothyroidism, hypogonadism, impaired glucose tolerance and Type 2 diabetes, therefore improving survival and patients' quality of life. Furthermore, outcomes should continue to improve in the future. Starting relatively intensive chelation in younger children may prevent short stature and abnormal pubertal maturation, as well as other iron-related morbidities. In addition, further information should become available on the use of other combinations in chelation treatment, some of which have only been used in a very limited fashion so far. New safe oral chelators may also become available that may offer additional ease of use. All these advances in management do require absolute cooperation and understanding on behalf of children's parents and subsequently the adult themself. Only with such cooperation can normal long-term survival be achieved as it is likely that adherence to treatment is the primary barrier to longevity.
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Affiliation(s)
- Vasilios Berdoukas
- The Division of Hematology/Oncology, The Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027-6016, USA.
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Marro K, Otto R, Kolokythas O, Shimamura A, Sanders JE, McDonald GB, Friedman SD. A simulation-based comparison of two methods for determining relaxation rates from relaxometry images. Magn Reson Imaging 2011; 29:497-506. [PMID: 21333480 DOI: 10.1016/j.mri.2010.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 09/27/2010] [Accepted: 11/28/2010] [Indexed: 10/18/2022]
Abstract
When assessing liver iron content using relaxometry, an average relaxation rate (R1, R2 or R2*) is usually determined from a region of interest or the entire liver. This is commonly performed by fitting the signal decay in individual voxels to an appropriate relaxation function. The voxel-level parameters resulting from the fits are combined to determine the average relaxation rate, and an empirically derived calibration curve is used to convert this single value to iron content. The goal of this study was to compare the precision and accuracy of this voxel-wise fitting to an alternative method that relies on first averaging the signals from all voxels within the region of interest and then determining the relaxation rate from a single fit. Systematic differences were observed when both methods were applied to clinical images. Mathematical simulations were employed to determine which method provided more robust estimates of the true relaxation rate. The mathematical simulations were then expanded to include a range of conditions expected in typical relaxometry images. The results show that voxel-wise fitting skews the relaxation rate estimates and increases variance, particularly when the true relaxation rate is moderate to fast, as it would be in liver with high iron content. The potential impact of these results on clinical decisions is discussed.
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Affiliation(s)
- Kenneth Marro
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, USA.
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Restaino G, Meloni A, Positano V, Missere M, Rossi G, Calandriello L, Keilberg P, Mattioni O, Maggio A, Lombardi M, Sallustio G, Pepe A. Regional and global pancreatic T*2 MRI for iron overload assessment in a large cohort of healthy subjects: normal values and correlation with age and gender. Magn Reson Med 2010; 65:764-9. [PMID: 21337408 DOI: 10.1002/mrm.22640] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 07/22/2010] [Accepted: 08/26/2010] [Indexed: 12/20/2022]
Abstract
Multiecho gradient-echo T*2 magnetic resonance imaging is a well-established technique for iron overload assessment but there are few reports concerning the pancreas. The aim of this work was to assess the feasibility and reproducibility of the magnetic resonance imaging for measuring pancreatic regional and global T*2 values, to establish the lower limit of normal in a large cohort of healthy subjects and to correlate the measured values with age and gender. One hundred and twenty healthy subjects (61 males, 51±17 years) underwent magnetic resonance imaging (1.5T) using a multiecho gradient-echo T*2 sequence. T*2 measurements were performed in pancreatic head, body, and tail. The global value was calculated as the mean. Measurement of pancreatic T*2 values was feasible in all subjects. For the T*2 global value the coefficient of variation for intraoperator and interoperator reproducibility were 7.7% and 13%, respectively. The global T*2 values ranged from 24 to 52 ms with the lower limit of normal of 26 ms. There were no significant differences among the regional pancreatic T*2 values. No significant correlation was found between T*2 and patient age or gender. In conclusion, pancreatic T*2 measurements appear to be feasible, reproducible, nontime-consuming and reliable. Gender- and age-related differences concerning pancreatic T*2 were not found.
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Affiliation(s)
- Gennaro Restaino
- Department of Radiology, John Paul II Catholic University, Campobasso, Italy
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Matter RM, Allam KE, Sadony AM. Gradient-echo magnetic resonance imaging study of pancreatic iron overload in young Egyptian beta-thalassemia major patients and effect of splenectomy. Diabetol Metab Syndr 2010; 2:23. [PMID: 20398341 PMCID: PMC2873247 DOI: 10.1186/1758-5996-2-23] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 04/15/2010] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Thalassemic patients suffer from diabetes mellitus secondary to hemosiderosis. AIMS The study aimed to evaluate pancreatic iron overload by T2*-weighted Gradient-echo magnetic resonance imaging (MRI) in young beta-thalassemia major patients and to correlate it with glucose disturbances, hepatic hemosiderosis, serum ferritin and splenectomy. METHODS Forty thalassemic patients (20 non diabetic, 10 diabetic, and 10 with impaired glucose tolerance) were recruited from Pediatric Hematology Clinic, in addition to 20 healthy controls. All patients underwent clinical assessment and laboratory investigations included complete blood count, liver function tests, serum ferritin and oral glucose tolerance test (OGTT). A T2*-weighted gradient-echo sequence MRI was performed with 1.5 T scanner and signal intensity ratio (SIR) of the liver and the pancreas to noise were calculated. RESULTS Significant reduction in signal intensity ratio (SIR) of the liver and the pancreas was shown in thalassemic patients compared to controls (P < 0.0001), Thalassemic patients with abnormal glucose tolerance; including diabetics and thalassemics with impaired glucose tolerance; displayed a higher degree of pancreatic and hepatic siderosis compared to thalassemics with normal glucose tolerance or controls (P < 0.001, P < 0.0001). Splenectomized thalassemic patients had significantly lower SIR of pancreas compared to non splenectomized patients (P < 0.05). A strong correlation was present between hepatic and pancreatic siderosis in studied patients (P < 0.001). CONCLUSIONS pancreatic siderosis can be detected by T2* gradient-echo MRI since childhood in thalassemic patients, and is more evident in patients with abnormal glucose tolerance. After splenectomy, iron deposition may be accelerated in the pancreas. Follow up of thalassemic patients using pancreatic MRI together with intensive chelation therapy may help to prevent the development of overt diabetes.
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Affiliation(s)
- Randa M Matter
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
| | - Khalid E Allam
- Department of Diagnostic Radiology, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
| | - Amany M Sadony
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo 11566, Egypt
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Abstract
Accurate evaluation of iron overload is necessary to establish the diagnosis of hemochromatosis and guide chelation treatment in transfusion-dependent anemia. The liver is the primary site for iron storage in patients with hemochromatosis or transfusion-dependent anemia, therefore, liver iron concentration (LIC) accurately reflects total body iron stores. In the past 20 years, magnetic resonance imaging (MRI) has emerged as a promising method for measuring LIC in a variety of diseases. We review the potential role of MRI in LIC determination in the most important disorders that are characterized by iron overload, that is, thalassemia major, other hemoglobinopathies, acquired anemia, and hemochromatosis. Most studies have been performed in thalassemia major and MRI is currently a widely accepted method for guiding chelation treatment in these patients. However, the lack of correlation between liver and cardiac iron stores suggests that both organs should be evaluated with MRI, since cardiac disease is the leading cause of death in this population. It is also unclear which MRI method is the most accurate since there are no large studies that have directly compared the different available techniques. The role of MRI in the era of genetic diagnosis of hemochromatosis is also debated, whereas data on the accuracy of the method in other hematological and liver diseases are rather limited. However, MRI is a fast, non-invasive and relatively accurate diagnostic tool for assessing LIC, and its use is expected to increase as the role of iron in the pathogenesis of liver disease becomes clearer.
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House MJ, St. Pierre TG, Milward EA, Bruce DG, Olynyk JK. Relationship between brain R
2
and liver and serum Iron concentrations in elderly men. Magn Reson Med 2010; 63:275-81. [DOI: 10.1002/mrm.22263] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Papakonstantinou O, Alexopoulou E, Economopoulos N, Benekos O, Kattamis A, Kostaridou S, Ladis V, Efstathopoulos E, Gouliamos A, Kelekis NL. Assessment of iron distribution between liver, spleen, pancreas, bone marrow, and myocardium by means of R2 relaxometry with MRI in patients with beta-thalassemia major. J Magn Reson Imaging 2009; 29:853-9. [PMID: 19306409 DOI: 10.1002/jmri.21707] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To investigate the correlation between the degree of hepatic, splenic, pancreatic, vertebral bone marrow (VBM), and myocardial siderosis, as expressed by relaxation rate (R2 = 1/T2) values, in patients with thalassemia. MATERIALS AND METHODS R2 relaxation rate values of liver, spleen, VBM, pancreas, and myocardium were estimated in 68 consecutive transfusion-dependent patients with beta-thalassemia major and 10 healthy controls using a respiratory triggered 16-echo Carr-Purcell-Meiboom-Gill (CPMG) spin echo sequence. RESULTS Hepatic R2 values were significantly increased in all 68 patients; VBM, pancreatic, and myocardial R2 values were increased in 67/68, 35/47, and 47/61 patients, whereas five patients showed decreased pancreatic R2 attributed to fatty degeneration. Of the 39 nonsplenectomized patients, splenic R2 values were decreased in 30 and normal in nine patients. Hepatic R2 values correlated with splenic (r = 0.63, P < 0.001), VBM (r = 0.52, P < 0.001), but not with myocardial and pancreatic R2 values. CONCLUSION Despite positive correlations between the degree of hepatic, splenic, and VBM siderosis, as expressed by respective R2 values, there was variability of iron distribution patterns in thalassemic patients. Unpredictable patterns of iron distribution may be seen, such as normal signal of the spleen in the presence of siderotic liver, resembling primary hemochromatosis. Fatty degeneration of the pancreas was not uncommon.
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T2* relaxometry in liver, pancreas, and spleen in a healthy cohort of one hundred twenty-nine subjects-correlation with age, gender, and serum ferritin. Invest Radiol 2009; 43:854-60. [PMID: 19002057 DOI: 10.1097/rli.0b013e3181862413] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To assess T2* values of liver, pancreas, and spleen in a healthy cohort and to compare the gained values with serum ferritin levels and anthropometric data. In addition, the relationship of T2* between the 3 organs was investigated. MATERIALS AND METHODS One hundred twenty-nine healthy subjects (85 women, 44 men) were examined on a 1.5-T magnetic resonance whole-body unit. Age ranged from 20 to 70 years (mean age, 47.9 +/- 11.4 years). A multislice fat-saturated breath-hold 2D multiecho gradient-echo sequence was applied for T2* measurement. To assess T2* values of the liver, pancreas, and spleen, T2* maps were calculated. The correlation of organ T2* with serum ferritin and anthropometric data (age, gender, body mass index) was investigated. RESULTS Measurement of T2* was feasible in all volunteers. A gender-related analysis revealed significant higher hepatic and splenic T2* values for women than for men (P < 0.01). For the pancreas, these differences could not be found. A significant negative correlation was found between hepatic T2*, splenic T2*, and serum ferritin (r = -0.62 liver, r = -0.64 spleen; P < 0.0001). In contrast, no such relationship was found for pancreatic T2* (r = -0.15). For women, a statistically significant age-dependent increase was found for splenic T2* values. CONCLUSION Using a fast quantitative T2* magnetic resonance imaging technique, it was possible to gain insights into the iron metabolism of a healthy cohort. Gender- and age-related differences concerning T2* and serum ferritin levels were found in the liver and spleen, but not in the pancreas.
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Fischer R, Harmatz PR. Non-invasive assessment of tissue iron overload. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2009; 2009:215-221. [PMID: 20008201 DOI: 10.1182/asheducation-2009.1.215] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In recent years, there has been increasing interest in non-invasive iron measurement, especially of the liver and heart, in patients with iron overload. Serum ferritin still remains an essential monitoring parameter in intervals between liver iron measurements; however, confounding factors such as inflammation, chelation treatment changes and the specific disease have to be taken into account. Liver iron measurements can now routinely be performed in clinical applications either by quantitative magnetic resonance imaging (MRI) using the transverse magnetic relaxation rate R(2) or R(2)* (1/T(2)*) or by biomagnetic liver susceptometry. For iron measurements in the heart, the single-breathhold multi-echo MRI-R(2)* method has become a standard modality and is now applied in clinical settings beyond research studies. In other tissues like the pancreas, pituitary, and brain, different MRI methods are employed, but their clinical benefit has yet to be proven.
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Affiliation(s)
- Roland Fischer
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Argyropoulou MI, Astrakas L. MRI evaluation of tissue iron burden in patients with beta-thalassaemia major. Pediatr Radiol 2007; 37:1191-200; quiz 1308-9. [PMID: 17710390 PMCID: PMC2292491 DOI: 10.1007/s00247-007-0567-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 05/07/2007] [Accepted: 05/31/2007] [Indexed: 11/24/2022]
Abstract
beta-Thalassaemia major is a hereditary haemolytic anaemia that is treated with multiple blood transfusions. A major complication of this treatment is iron overload, which leads to cell death and organ dysfunction. Chelation therapy, used for iron elimination, requires effective monitoring of the body burden of iron, for which serum ferritin levels and liver iron content measured in liver biopsies are used as markers, but are not reliable. MRI based on iron-induced T2 relaxation enhancement can be used for the evaluation of tissue siderosis. Various MR protocols using signal intensity ratio and mainstream relaxometry methods have been used, sometimes with discrepant results. Relaxometry methods using multiple echoes achieve better sampling of the time domain in which relaxation mechanisms take place and lead to more precise results. In several studies the MRI parameters of liver siderosis have failed to correlate with those of other affected organs, underlining the necessity for MRI iron evaluation in individual organs. Most studies have included children in the evaluated population, but MRI data on very young children are lacking. Wider application of relaxometry methods is indicated, with the establishment of universally accepted MRI protocols, and further studies, including young children, are needed.
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Affiliation(s)
- Maria I Argyropoulou
- Radiology Department, Medical School, University of Ioannina, Ioannina, GR-45110, Greece.
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